The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Prescription for ceftriaxone PO every 12 hours.

A 26-year-old client.

Blood pressure is 80/48 mm Hg.

Admitted after a motor vehicle collision.

Answer and Explanation

The Correct Answer is C

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

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Correct Answer is A

Explanation

A. Reduce the stimuli in the area before continuing the teaching is the best action. Sensory overload can interfere with a client's ability to learn effectively. By reducing distractions and environmental stimuli, the nurse can create a more conducive learning environment.

B. Reassure the client that the skill is not difficult to learn may be helpful, but it does not address the immediate issue of sensory overload. The client needs to be in an environment where they can focus and process information before reassurance is effective.

C. Provide the client with step-by-step written instructions may be helpful later, but in the context of sensory overload, the priority is to first reduce the stimuli. Written instructions can be given once the client is in a calmer state.

D. Demonstrate the skill, speaking slowly and using simple terms is a helpful teaching strategy, but if the client is experiencing sensory overload, the first step should be to reduce the environmental stimuli. Once the environment is conducive to learning, the nurse can proceed with demonstrating the skill.

A. Assess the client for signs of diminished circulation in the hands. B. Proceed with teaching the client how to walk with the crutches. C. Ask the client to sit down while the crutch length is adjusted. D. Confer with the physical therapist for correct crutch size.

Correct Answer is B

Explanation

A. Assess the client for signs of diminished circulation in the hands is unnecessary at this stage, as the primary concern is ensuring proper crutch fit and teaching safe use.

B. Proceed with teaching the client how to walk with the crutches is correct because a space of three finger-widths between the crutch and the axilla indicates proper crutch height. This prevents nerve damage and discomfort in the axilla.

C. Ask the client to sit down while the crutch length is adjusted is not needed since the crutches are already appropriately adjusted based on the observed spacing.

D. Confer with the physical therapist for correct crutch size is unnecessary because the nurse can confirm that the crutches are properly fitted based on standard guidelines.

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The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is A

Explanation

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is B

Explanation

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